BACKGROUND The ideal timing for surgery in asymptomatic chronic aortic regurgitation (AR) remains unclear. New thresholds for left ventricular ejection fraction (LVEF), left ventricular (LV) indexed end-systolic volume (iESV), and global longitudinal strain (GLS) have been associated with mortality in these patients. These represent markers of early LV dysfunction. OBJECTIVES The authors sought to assess the relationship between these markers (LVEF <60%, iESV ≥45 mL/m2, and GLS worse than -15%) and mortality, comparing them to Class I/IIa American College of Cardiology/American Heart Association guideline recommendations and absence of any of these. METHODS A total of 673 asymptomatic patients with chronic clinically significant (≥ moderate-severe) AR between 2004 and 2019 at a single referral center were retrospectively analyzed. The primary study outcome was all-cause mortality. RESULTS Mean age was 57 ± 17 years, 97 (14%) were female, 293 (45%) had hypertension, and 273 (41%) had an abnormal number of valve cusps. Aortic valve replacement was performed in 281 (48%) patients, and 69 (10%) died while under surveillance (without aortic valve replacement). LVEF <60% was present in 296 (44%) patients, 122 (25%) of 482 had GLS worse than -15%, and 261 (39%) had iESV ≥45 mL/m2. Mortality under surveillance was highest when Class I/IIa recommendations were present (HR: 4.22; 95% CI: 2.15-8.29), followed by the presence of 1 or more markers of early LV dysfunction (HR: 2.18; 95% CI: 1.21-3.92); no markers was used as the reference (all, P < 0.05). LVEF showed the strongest association with mortality, statistically slightly better than GLS and iESV. In the absence of Class I/IIa recommendations, 1 marker of early LV dysfunction was associated with higher, although not statistically significant, mortality compared with no markers (P = 0.063), followed by 2 markers; highest mortality was when all 3 markers were present (HR: 5.46; 95% CI: 2.51-11.90; P < 0.001). CONCLUSIONS Patients with asymptomatic clinically significant chronic AR incur a survival penalty when Class I/IIa guideline recommendations are attained. In patients without these recommendations, at least 2 markers of early LV dysfunction identify those with higher mortality risk who may benefit from early surgery.

中文翻译：

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无症状主动脉瓣反流中早期左心室功能障碍的超声心动图标志物：是时候改变指南了吗？


背景 无症状慢性主动脉瓣反流 （AR） 手术的理想时机尚不清楚。左心室射血分数 （LVEF） 、左心室索引收缩末期容积 （iESV） 和整体纵向应变 （GLS） 的新阈值与这些患者的死亡率相关。这些代表早期 LV 功能障碍的标志物。目的作者试图评估这些标志物 （LVEF <60%， iESV ≥45 mL/m2， GLS 差于 -15%） 与死亡率之间的关系，将它们与 I/IIa 级美国心脏病学会/美国心脏协会指南建议进行比较，并且没有这些。方法 回顾性分析 2004 年至 2019 年在单个转诊中心共收治 673 例无症状的慢性临床意义 （≥ 中重度） AR 患者。主要研究结局是全因死亡率。结果 平均年龄 57 ± 17 岁，女性 97 例 （14%），高血压 293 例 （45%） ，瓣尖数量异常 273 例 （41%）。281 例 （48%） 患者进行了主动脉瓣置换术，69 例 （10%） 在监测期间死亡 （未进行主动脉瓣置换术）。296 例 （44%） 患者存在 LVEF <60%，482 例患者中有 122 例 （25%） 的 GLS 低于 -15%，261 例 （39%） 的 iESV ≥45 mL/m2。当存在 I/IIa 类建议时，监测中的死亡率最高 （HR： 4.22;95% CI： 2.15-8.29），其次是存在 1 个或多个早期 LV 功能障碍标志物 （HR： 2.18;95% CI： 1.21-3.92）;无标记物作为参考 （全部， P < 0.05）。LVEF 与死亡率的相关性最强，统计学上略优于 GLS 和 iESV。 在没有 I/IIa 类推荐的情况下，与无标志物相比，1 个早期 LV 功能障碍标志物与较高的死亡率相关，尽管没有统计学意义 （P = 0.063），其次是 2 个标志物;当所有 3 个标志物都存在时死亡率最高 （HR： 5.46;95% CI： 2.51-11.90;P < 0.001）。结论 当达到 I/IIa 类指南推荐时，无症状临床显着的慢性 AR 患者会受到生存损失。在没有这些建议的患者中，至少 2 个早期 LV 功能障碍标志物可识别可能从早期手术中受益的死亡风险较高的患者。